Acute Hemolytic Transfusion Reaction (AHTR), anti-A, clerical error

Status:

Ready to upload

Record number:

1271

Adverse Occurrence type:

Acute Hemolytic Reaction

MPHO Type:

Red blood cells

Estimated frequency:

Case Report

Time to detection:

hours

Alerting signals, symptoms, evidence of occurrence:

Patient was undergoing operation and was under general anesthesia. Patient received 1 unit of AB Rh-positive blood and after several hours became hypotensive with profuse bleeding in the operation field. AB Rh-positive blood was transfused again and became anaemic with Hb 6.8 g/dL, Hct 24% and had signs of disseminated intravascular coagulation.

Demonstration of imputability or root cause:

Transfusion reaction work up re-typing of pre-transfusion sample documented patient to be group O, not AB as previously recorded.

Imputability grade:

3 Definite/Certain/Proven

Groups audience:

Clinical complications

Keywords:

AHTR (acute hemolytic transfusion reaction)

References:

Acute transfusion reaction. A case report.

Reference attachment:

* AHTR, clerical error, Galesic, 1997.pdf

Suggest references:

Galesic, K and Ratkovic, I. (1997). Acute transfusion reaction. A case report. Nephron 77(1):121.

Expert comments for publication:

Clear case of compound errors with failure to document proper blood type followed by failure to recognize signs of acute hemolytic transfusion reaction and second incompatible unit given. Authors ascribe recovery to plasmapheresis through recovery may have occurred with other supportive care.